Introduction to MedDRA: Coding and Data Analysis · Narrative. Narrative vignette. A 75-year-old...

Introduction to MedDRA:Coding and Data Analysis

Jane Knight42nd European Cystic Fibrosis Conference5th June 2019

Preparatory Learning

What do we already know about MedDRA?1.2.3.4.5.6.7.8.9.10.

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What is MedDRA?

Med = MedicalD = Dictionary forR = RegulatoryA = Activities

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MedDRA Definition

MedDRA is a clinically-validated international medical terminology used by regulatory authorities and the regulated biopharmaceutical industry. The terminology is used through the entire regulatory process, from pre-marketing to post-marketing, and for data entry, retrieval, evaluation, and presentation.

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MedDRA’s Purpose

• Facilitate the exchange of clinical information through standardization

• Important tool for product evaluation, monitoring, communication, electronic records exchange, and oversight

• Supports coding (data entry) and retrieval and analysis of clinical information about human medical products including pharmaceuticals, biologics, vaccines, and drug-device combination products

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MedDRA Users Profile

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• As of January 2019–5,700 Subscribing organizations (MSSO+JMO)

–122 Countries• Graph shows types of

subscribing organizations

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MedDRA Users By Country

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Scope of MedDRA

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Medical conditionsIndications

Investigations (tests, results)Medical and surgical proceduresMedical, social, family history

Medication errorsProduct quality issuesDevice-related issuesProduct use issues

Pharmacogenetic termsToxicologic issues

Standardized queries

Not a drug dictionary

Not an equipment, device,diagnostic product dictionary

Clinical trial study design terms

Patient demographicterms

Frequency qualifiers

Numerical values forresults

Severity descriptors

INOUT

MedDRA Structure

System Organ Class (SOC) (27)

High Level Group Term (HLGT) (337)

High Level Term (HLT) (1,737)

Preferred Term (PT) (23,708)

Lowest Level Term (LLT) (80,262)

MedDRA Version 22.0000281 9

Examples of Cystic Fibrosis Terms

• Other CF terms include–Gastrointestinal–Hepatic–Pancreatic–CF gene carrier

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Codes and Languages

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A Multi-Axial Terminology

• Multi-axial = the representation of a medical concept in multiple SOCs–Allows grouping by different classifications–Allows retrieval and presentation via different data sets

• All PTs assigned a primary SOC–Determines which SOC will represent a PT during

cumulative data outputs–Prevents “double counting”–Supports standardized data presentation–Pre-defined allocations should not be changed by users

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SOC = Respiratory, thoracic andmediastinal disorders(Secondary SOC)

HLGT = Respiratory tract infections

HLT = Viral upper respiratorytract infections

HLT = Influenza viral infections

HLGT = Viral infectious disorders

SOC = Infections and infestations

(Primary SOC)

PT = Influenza

A Multi-Axial Terminology (cont)

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Rules for Primary SOC Allocation

• PTs represented in only one SOC are automatically assigned that SOC as primary

• PTs for diseases, signs and symptoms are assigned to prime manifestation site SOC

• Congenital and hereditary anomalies terms have SOC Congenital, familial and genetic disorders as Primary SOC

• Neoplasms terms have SOC Neoplasms benign, malignant and unspecified (incl cysts and polyps) as Primary SOC – Exception: Cysts and polyps have prime manifestation

site SOC as Primary SOC• Infections and infestations terms have SOC Infections

and infestations as Primary SOC000281 14

Primary SOC Priority

If a PT links to more than one of the exceptions, the following priority will be used to determine primary SOC:1st: Congenital, familial and genetic disorders2nd: Neoplasms benign, malignant and

unspecified (incl cysts and polyps)3rd: Infections and infestations

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A Multi-Axial Terminology (cont)

PTs in the following SOCs only appear in that particular SOC and not in others, i.e., they are not multi-axial

• Investigations•Surgical and medical procedures•Social circumstances

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Can You Select the Primary SOC for This PT?

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PT HLT HLGT SOCCongenital HIV infection

Viral infections congenital

Infections and infestations congenital

Congenital, familial and genetic disorders

Congenital neonatal infections

Neonatal and perinatal conditions

Pregnancy, puerperium and perinatal conditions

Retroviral infections

Viral infectious disorders

Infections and infestations

Acquired immunodeficiency syndromes

Immunodeficiency syndromes

Immune system disorders

MSSO’s MedDRA Browsers

• MedDRA Desktop Browser (MDB)– Download MDB and release files from MedDRA website

• MedDRA Web-Based Browser (WBB)– https://tools.meddra.org/wbb/

• Features– Both require MedDRA ID and password – View/search MedDRA and SMQs– Support for all MedDRA languages– Language specific interface– Ability to export search results and Research Bin to local

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https://tools.meddra.org/wbb/

MedDRA Browsers

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MedDRA Mobile Browser

• MedDRA Mobile Browser for use on phones and tablets

• Accessed at: mmb.meddra.org

• Requires your organisation’s MedDRA ID and Password

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Coding in everyday life?

PtC Documents

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PtC Category PtC Document Purpose Languages Release CycleTerm Selection MedDRA Term Selection:

Points to ConsiderPromote accurate and consistent coding with MedDRA

English and Japanese

Updated with each MedDRA release

MedDRA Term Selection: Points to Consider Condensed Version

Shorter version focusing on general coding principles to promote accurate and consistent use of MedDRA worldwide

All MedDRA languages (except English and Japanese)

Update as needed

Data Retrieval and Presentation

MedDRA Data Retrieval and Presentation: Points to Consider

Demonstrate how data retrieval options impact the accuracy and consistency of data output


Updated with each MedDRA release

MedDRA Data Retrieval and Presentation: Points to Consider Condensed Version

Shorter version focusing on general retrieval and analysis principles to promote accurate and consistent use of MedDRA worldwide

All MedDRA languages (except English and Japanese)

Update as needed

General MedDRA Points to Consider Companion Document

More detailed information, examples, and guidance on specific topics of regulatory importance. Intended as a “living” document with frequent updates based on users’ needs. First edition covers data quality and medication errors.


Updated as needed

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• Provides term selection advice for industry and regulatory purposes

• Objective is to promote accurate and consistent term selection to facilitate a common understanding of shared data

• Recommended to be used as basis for individual organization’s own coding conventions

MedDRA Term Selection: Points to Consider (MTS:PTC)

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MTS:PTC Points of Note

• In some cases with more than one option for selecting terms, a “preferred option” is identifiedbut this does not limit MedDRA users to applying that option. Organizations should be consistent in their choice of option.

• Section 4.1 – Versioning (Appendix)–4.1.1 Versioning methodologies–4.1.2 Timing of version implementation

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General Term Selection Principles

• Quality of Source Data• Quality Assurance• Do Not Alter MedDRA• Always Select a Lowest Level Term• Select Only Current Lowest Level Terms• When to Request a Term• Use of Medical Judgment in Term Selection• Selecting More than One Term• Check the Hierarchy• Select Terms for All Reported Information, Do Not

Add Information

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Quality of Source DataQuality Assurance

• Quality of original information impacts quality of output

• Obtain clarification of data• Can be optimized by careful design of data

collection forms and proper training of staff• Organizations’ coding guidelines should be

consistent with MTS:PTC• Review of term selection by qualified individuals• Human oversight of automated coding results

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Do Not Alter MedDRA

• MedDRA is a standardized terminology with a pre-defined term hierarchy

• Users must not make ad hoc structural alterations, including changing the primary SOC allocation

• If terms are incorrectly placed, submit a change request to the MSSO

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Always Select a Lowest Level TermSelect Only Current LLTs

• Lowest Level Term that most accurately reflects the reported verbatim information should be selected

• Degree of specificity may be challenging–Example: “Abscess on face” select “Facial

abscess,” not simply “Abscess”• Select current LLTs only

–Non-current terms for legacy conversion/historical purposes

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When to Request a TermUse of Medical Judgment

• Avoid company-specific “work-arounds” for MedDRA deficiencies. If concept not adequately represented in MedDRA, submit Change Request to MSSO.

• If no exact match in MedDRA, use medical judgment to match to an existing term that adequately represents the concept

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Selecting More than One TermCheck the Hierarchy

• Can select more than one LLT to represent reported information. Document procedures. –Selecting one term may lead to loss of specificity–Selecting more than one term may lead to redundant

counts• Check the hierarchy above a selected LLT (PT, HLT,

HLGT, SOC) to ensure placement accurately reflects meaning of reported term

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Select Terms for All Reported Information

• Select terms for every AR/AE reported, regardless of causal association

• Select terms for device-related events, product quality issues, medication errors, medical and social history, investigations and indications as appropriate

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Do Not Add Information

• Do not make diagnosis if only signs/symptoms reported

Reported LLT Selected Comment

Abdominal pain, increased serum

amylase, and increased serum lipase

Abdominal pain

It is inappropriate to assign an LLT for

diagnosis of “pancreatitis”

Serum amylase increased

Lipase increased

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Assessing the Reported Information

• Consider what is being reported. Is it a:– Clinical condition - Diagnosis, sign or symptom?– Indication?– Test result?– Injury?– Procedure?– Medication error?– Product use issue?– Product quality issue?– Social circumstance?– Device issue?– Procedural complication?

– Is it a combination of these?

The type of report will influence the way you search for a suitable LLT. It may indicate in which SOC you expect to find the closest match.

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Coding Example -Narrative

Narrative vignetteA 75-year-old male receiving Drug X for rheumatoid arthritis developed symptomatic aortic valve stenosis. The patient’s medical history is significant for colon cancer and cigarette smoking. He underwent an aortic valve replacement and developed a sternal wound infection three days post-surgery.

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Coding Example 1

Specificity

The patient suffered from an allergic reaction to an antibiotic

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Coding Example 2

Symptoms

The patient states she has been experiencing increasingly frequent episodes of coughing

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Coding Example 3

Investigations

Lung function tests indicate a decrease in FEV1 and FVC

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Coding Example 4

Medication errors

Patient accidentally took drug Y instead of drug X and became short of breath

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Coding Example 5

Patient demographics

A 2 day old baby was noted to have a mild fever

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Coding Example 6

Indications

The patient was prescribed Drug X to preventMycobacterium avium complex lung infection

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Coding Example 7

Specificity

Following the procedure, the patient experienced several days of constipation

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Coding Example 8

Surgical and medical procedures

His breathing improved markedly with more regular chest physical therapy

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Coding Example 9

Social circumstances

The patient was confined to a wheelchair

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Term Selection Points

• Diagnoses and Provisional Diagnoses with or without Signs and Symptoms

• Death and Other Patient Outcomes• Suicide and Self-Harm• Conflicting/Ambiguous/Vague Information• Combination Terms• Age vs. Event Specificity• Body Site vs. Event Specificity• Location-Specific vs. Microorganism-Specific Information• Modification of Pre-existing Conditions• Exposures During Pregnancy and Breast Feeding• Congenital Terms• Neoplasms• Medical and Surgical Procedures• Investigations

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Term Selection Points (cont)

• Medication Errors, Accidental Exposures and Occupational Exposures

• Misuse, Abuse and Addiction• Transmission of Infectious Agent via Product• Overdose, Toxicity and Poisoning• Device-related Terms• Drug Interactions• No Adverse Effect and “Normal” Terms• Unexpected Therapeutic Effect• Modification of Effect• Social Circumstances• Medical and Social History• Indication for Product Use• Off Label Use• Product Quality Issues

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Diagnoses and Provisional Diagnoses

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SINGLE DIAGNOSIS

DEFINITIVE DIAGNOSIS PROVISIONAL DIAGNOSIS

Single diagnosis without signs and symptoms

•Diagnosis (only possible option)

Single provisional diagnosis without signs and symptoms

•Provisional diagnosis (only possible option)

Example: “Myocardial infarction” select “Myocardial infarction”

Example: “Possible myocardial infarction” select “Myocardial infarction” (select term as if definitive diagnosis)

Similar principles apply for multiple diagnoses

Diagnoses and Provisional Diagnoses (cont)

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SINGLE DIAGNOSISDEFINITIVE DIAGNOSIS PROVISIONAL DIAGNOSIS

Single diagnosis with signs/ symptoms

•Preferred: Diagnosis only

Single provisional diagnosis with signs/symptoms

•Preferred: Provisional diagnosis and signs/symptoms

Example: “Anaphylactic reactionwith rash, dyspnoea, hypotension, and laryngospasm” select “Anaphylactic reaction”

Example: “Possible myocardial infarction with chest pain,dyspnoea, diaphoresis” select “Myocardial infarction” “Chest pain”, “Dyspnoea”, and “Diaphoresis”



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SINGLE DIAGNOSISDEFINITIVE DIAGNOSIS PROVISIONAL DIAGNOSIS

Single diagnosis with signs/ symptoms

•Alternate: Diagnosis and signs/symptoms

Single provisional diagnosis with signs/symptoms

•Alternate: Signs/symptoms only (as provisional diagnosis may change

Example: “Anaphylactic reactionwith rash, dyspnoea, hypotension, and laryngospasm” select “Anaphylactic reaction”, “Rash”, “Dyspnoea”, Hypotension”, and “Laryngospasm”

Example: “Possible myocardial infarction with chest pain,dyspnoea, diaphoresis” select “Chest pain”, “Dyspnoea”, and “Diaphoresis”



• Always include signs/symptoms not associated with diagnosis

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Reported LLT Selected

Myocardial infarction, chest pain, dyspnoea, diaphoresis, ECG changes and jaundice

Myocardial infarction Jaundice (note that jaundice is

not typically associated with myocardial infarction)

Micro-organism Specific Infection

• Select term to capture infecting micro-organism at specified site

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Micro-organism Specific Infection

• If no appropriate combination term exists, the preferredapproach is to select two LLTs for both pathogen and site

• The alternate approach is to choose to select only one term

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Conflicting/Ambiguous Information

• First, try to obtain more specific informationReported LLT Selected Comment

Hyperkalaemia with a serum potassium of 1.6

mEq/L

Serum potassium abnormal

LLT Serum potassium abnormal covers both of the reported concepts

(note: serum potassium of 1.6 mEq/L is a low result,

not high)

GU pain Pain

“GU” could be either “genito-urinary” or “gastric

ulcer”. If additional information is not available, then select a term to reflect

the information that is known, i.e., LLT Pain

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Vague Information

• First, try to obtain more specific information


Turned green Unevaluable event

“Turned green” reported alone is vague; this could refer to a patient condition or even to a product (e.g.,

pills)

Patient had a medical problem of unclear type

Ill-defined disorder

Since it is known that there is some form of a

medical disorder, LLT Ill-defined disorder can be

selected

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Combination Terms

• One condition is more specific than the other

• A MedDRA combination term is available

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Arrhythmia due to atrial fibrillation Atrial fibrillation

Hepatic function disorder (acute hepatitis) Hepatitis acute


Retinopathy due to diabetes Diabetic retinopathy

Rash with itching Itchy rash

Combination Terms (cont)

• If splitting provides more clinical information, select more than one term

• In all cases of combination terms, apply medical judgment

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Diarrhoea and vomiting DiarrhoeaVomiting

Wrist fracture due to fall Wrist fractureFall

Investigations

• Medical condition vs. investigation result


Hypoglycaemia HypoglycaemiaLLT Hypoglycaemia

links to SOC Metabolism and

nutrition disorders

Decreased glucose Glucose decreasedLLT Glucose decreased

links to SOC Investigations

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Investigations (cont)

• Unambiguous investigation result

• Ambiguous investigation resultReported LLT Selected Comment

His glucose was 40 Glucose abnormal

No units have been reported. Select LLTGlucose abnormal if

clarification cannot be obtained.


Glucose 40 mg/dL Glucose lowGlucose is clearly

below the reference range

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Investigations (cont)

• Investigation results consistent with diagnosis

• Grouped investigation result termsReported LLT Selected Comment

Increased alkaline phosphatase,

increased SGPT, increased SGOT and

elevated LDH

Alkaline phosphatase increased

SGPT increasedSGOT increasedLDH increased

Select four individual terms. A single term

such as LLT Liver function tests

abnormal should notbe selected.

Reported LLT Selected CommentElevated potassium, K

7.0 mmol/L, and hyperkalaemia

HyperkalaemiaIt is not necessary to select LLT Potassium

increased

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MedDRA Coding Exercise

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Which LLT Would You Select?

Verbatim: “Became color blind in adolescence”

A. Color blindnessB. Blindness colorC. Colour blindness acquiredD. Color blindness acquired

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Verbatim: “Turned very greasy”

A. Ill-defined disorderB. Unevaluable eventC. Skin greasyD. Unevaluable reaction

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Verbatim: “Deliberately took an overdose”

A. Intentional overdoseB. Overdose NOSC. Deliberate overdoseD. Overdose

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Verbatim: “Four-year old accidentally took his mother’s medication”

A. Accidental overdose B. Accidental exposure to product by child C. Accidental drug intake by childD. Accidental ingestion

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Verbatim: “Infection after surgery”

A. InfectionB. Postoperative wound infection C. Surgical wound infectionD. Postoperative infection

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Verbatim: “Had GU”

A. Gastric ulcerB. Ill-defined disorderC. GUD. Unevaluable eventE. Genitourinary tract infection

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Verbatim: “Hypernatraemia (Serum sodium = 115 mEq/L)”

A. Serum sodium abnormalB. HypernatraemiaC. HyponatraemiaD. Serum sodium decreased

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Verbatim: “Death from multiple organ failure following haemorrhage post lung transplant”

A. Sudden death B. Death C. Multiple organ failureD. Lung transplant

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Verbatim: “Patient was found dead”

A. Death from natural causesB. Death C. Died in sleep D. Found dead

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Verbatim: “The hospital diagnosed a perinephric abscess due to Proteus spp.”

A. Proteus infectionB. Perinephric abscessC. Proteus infection AND Perinephric abscessD. Abscess bacterial

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Verbatim: “Died as a result of a suicide attempt”

A. Suicide gesture B. Attempted suicide C. Completed suicide D. Death

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Verbatim: “Abused by her father”

A. Physical abuseB. Child sexual abuseC. Child neglectD. Child abuse

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Verbatim: “After taking OTC NSAIDs, along with his prescribed antibiotic, he developed pain in her kidneys.”

A. Adverse reaction to antibioticsB. Nephrotoxicity C. Kidney painD. Drug interaction

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• Provides data retrieval and presentation options for industry or regulatory purposes

• Most effective when used in conjunction with MedDRA Term Selection: PTC document

• Recommended to be used as basis for individual organization’s own data retrieval conventions

MedDRA Data Retrieval and Presentation: Points to Consider (DRP:PTC)

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What is a Query?

Query

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Patient Registry

Query Strategy Tips• Define the condition• Develop inclusion/exclusion criteria• Good browser is key component• Search “non multi-axial” and “other/support” SOCs• Search a term’s “neighbors”, including secondary locations• Use grouping terms where applicable• Avoid using LLTs (Exception: species information at LLT

level in SOC Infections and infestations)• Store for future use• Review for impact of new MedDRA versions

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Complete the Circle (Connect the DOTSSS!)

Diagnosis/disease terms

Operations (Surgical and medical procedures)

Tests (Investigations)

Signs & symptoms

Social circumstances

Support SOCs (Other…)

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Standardised MedDRA Queries (SMQs)

• Collaboration between CIOMS (Council for International Organizations of Medical Sciences) and ICH (MSSO)

• Groupings of terms from one or more MedDRA SOCs related to medical condition or area of interest

• Terms relate to signs/symptoms, diagnoses, syndromes, physical findings, laboratory and other test data, etc.

• Intended to aid in case identification 000282 80

SMQ Benefits and Limitations

• Benefits– Application across multiple therapeutic areas– Validated reusable search logic– Standardized communication of safety information– Consistent data retrieval– Maintenance by MSSO/JMO

• Limitations– Do not cover all medical topics or safety issues– Will evolve and undergo further refinement even though

they have been tested during development

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SMQ in Production -Examples

• As of Version 22.0, a total of 104 level 1 SMQs in production• Agranulocytosis• Anaphylactic reaction• Cerebrovascular

disorders• Convulsions• Depression and

suicide/self-injury• Hepatic disorders• Hypersensitivity• Ischaemic heart disease• Lack of efficacy/effect

• Medication errors• Osteonecrosis• Peripheral neuropathy• Pregnancy and neonatal

topics• Pseudomembranous colitis• Rhabdomyolysis/myopathy• Severe cutaneous adverse

reactions• Systemic lupus

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MedDRA Term Inclusion

• SMQs are constructed at MedDRA PT level

• LLTs that are subordinate to an included PT are also included

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Narrow and Broad Searches

• “Narrow” scope – specificity (cases highly likely to be condition of interest)

• “Broad” scope – sensitivity (all possible cases)• “Broad search” = All broad + all narrow terms

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Narrow vs. Broad Example

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SMQ Lactic acidosis

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Narrow TermsBlood lactic acid increasedHyperlactacidaemiaLactic acidosis

Broad TermsAcid base balance abnormalAcidosisAnion gap abnormalAnion gap increasedBlood alkalinisation therapyBlood bicarbonate abnormalBlood bicarbonate decreasedBlood gases abnormalBlood lactic acid abnormalBlood pH abnormalBlood pH decreasedComa acidoticKussmaul respirationMetabolic acidosisPCO2 abnormalPCO2 decreasedUrine lactic acid increased

Algorithmic SMQs

• Some SMQs are designed to utilize algorithms

• Better case identification among broad search terms may result if cases are selected by a defined combination of selected terms

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Algorithmic SMQ Example

• Anaphylactic reaction (SMQ):– A case with any of the following PTs:

• Anaphylactic reaction• Anaphylactic shock• Anaphylactic transfusion reaction• Anaphylactoid reaction• Anaphylactoid shock• Circulatory collapse• Dialysis membrane reaction• Kounis syndrome• Procedural shock• Shock• Shock symptom• Type I hypersensitivity(Narrow search terms = Category A)

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Algorithmic SMQ Example (cont)

• Case = A (Narrow terms) • Or Term from Category B and term from Category C• Or Term from either Category B or Category C

plus Term from Category D

Category B –Upper airway/Respiratory

Category C –Angioedema/Urticaria, etc.

Category D –Cardiovascular/Hypotension

Acute respiratory failure

Allergic oedema Blood pressure decreased

Asthma Angioedema Blood pressure diastolic decreased

Bronchial oedema Erythema Blood pressure systolic decreased

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Hierarchical SMQs

• Some SMQs may develop as set of queries related to one another in a hierarchical relationship

• Not related to MedDRA standard hierarchy• One or more subordinate SMQs combined

to create a superordinate, more inclusive SMQ

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Hierarchical SMQ Example

Haematopoietic cytopenias

Haematopoietic cytopenias affecting more than one type

of blood cell

Haematopoietic erythropenia

Haematopoietic leukopenia

Haematopoietic thrombocytopenia

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Browser Demonstration SMQ View

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MedDRA Training Opportunities – Available for Users

• Free Face-to-Face (F2F) training – Coding with MedDRA– Safety Data Analysis and Standardised MedDRA Queries– Getting Started with MedDRA

• Free webinars – Getting Started with MedDRA– MedDRA Overview– MedDRA Coding Basics– Advanced MedDRA Coding– Data Analysis and Query Building with MedDRA– Standardised MedDRA Queries – What’s New with MedDRA (with each MedDRA release)

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Registration for Training

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MedDRA Training Opportunities – Available to All

• Free resources on MedDRA website–Slides for all F2F courses and webinars–Short videocasts on MedDRA-related topics

• Available in several languages• Can be downloaded or viewed directly on website• Help trainees prepare for F2F courses

• Webinars and videocasts available on new MedDRA MSSO YouTube Channel

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More Resources for MedDRA Users

• MedDRA website–Help Desk–Subscriptions–News and Events–MedDRA Best Practices document–Points to Consider documents–Terminology downloads–Training–Tools–MedDRA publications–User group meetings–Expert meetings

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MSSO Contacts

• Website–www.meddra.org

• Email–[email protected]

• Frequently Asked Questions–www.meddra.org/faq

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http://www.meddra.org/

mailto:[email protected]

http://www.meddra.org/faq

Introduction to MedDRA: Coding and Data Analysis · Narrative. Narrative vignette. A 75-year-old...

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